CASE REPORT Open Access

Dermoscopy of skin metastases from breastcancer: two case reportsAwatef Kelati* and Salim Gallouj

Abstract

Background: Cutaneous metastatic breast cancer is the most common cutaneous metastatic malignancy in women.The assessment of cutaneous metastatic disease can be perplexing because the clinical presentation appears similar toother skin malignancies like angiosarcoma or melanoma, or benign diseases like cellulitis and lymphedema. To date,only a limited number of dermoscopic images of cutaneous metastatic solid tumors, especially breast cancer, havebeen published.

Case presentation: The authors report two Moroccan cases highlighting dermoscopy as a quick tool to recognizeskin metastasis of breast cancer in two different clinical presentations. A 51-year-old Moroccan woman presentedwith nodules of various sizes on and around a mastectomy scar, and a 65-year-old Moroccan woman presentedwith cellulitis-like lesions on her chest wall and her back. Dermoscopic features were similar in the two cases withfindings of yellow central areas, polymorphic vessels, whitish bright lines, whitish structureless areas, and linearirregular fissure-like depressions on a pink-orange background.

Conclusions: The recognition of dermoscopic patterns of cutaneous metastasis of breast cancer is not only useful tofacilitate diagnosis at an early stage and to rule out other differentials, especially in difficult presentations such ascellulitis-like lesions or lymphedema, but it may also be used by physicians in monitoring mastectomy scars.

Keywords: Skin metastases from breast cancer on mastectomy scar, Dermoscopy

BackgroundMetastatic cutaneous lesions are seen more commonly inbreast cancer than in any other malignancy in women, ex-ceeding 20% of all cutaneous metastases [1]. The presenceof skin metastases signifies widespread systemic diseaseand a poor prognosis [2]. Patients present with a variety ofsymptoms ranging from non-painful, single or multiple,hard, firm, indurated skin to tiny seed-like solid papulesand large egg-sized lesions, with sometimes an edema ofthe skin of the breast, known as the orange peel sign,without any specific clinical diagnostic criteria. The chestwall, the abdomen, the back, and the upper extremities arecommon sites [3].Assessment of cutaneous metastatic disease after mastec-

tomy can be perplexing because the clinical presentationappears similar to other skin diseases such as cellulitis orlymphedema [1]. Although dermoscopy may provide a use-ful method for the differentiation between the diagnosis of

metastasis to the skin and non-neoplastic dermatologicaldiseases or other malignancies, the dermoscopic patternsof breast cancer metastases have not been well described.We report two cases of breast cancer metastases with

an emphasis on the dermoscopic patterns of the disease.

Case presentationThe authors report two Moroccan cases of dermoscopy inskin metastasis of breast cancer with two different clinicalpresentations; the dermoscopic examination was per-formed using a Dermatoscope Delta® 20 (Heine; Herrsching,Germany) with polarized light and without immersion.Case 1 was a 51-year-old Moroccan woman diagnosed

as having infiltrating ductal carcinoma of the left breast.Case 2 was a 65-year-old Moroccan woman diagnosed ashaving infiltrating ductal carcinoma of the right breast.They underwent mastectomy and axillary node dissectionfollowed with adjuvant hormone and chemotherapy. Aftera remission period of 14 months (Case 1) and 10 months(Case 2), they were referred to our hospital for painfullesions on the surface of their trunk, chest, and back.

* Correspondence: awatkelati@gmail.comDepartment of Dermatology, University Hospital of Fez, Fez, Morocco

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Kelati and Gallouj Journal of Medical Case Reports (2018) 12:273 https://doi.org/10.1186/s13256-018-1803-z

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For Case 1, a physical examination revealed irregularlydistributed pink nodules of various sizes with a large firm,indurated skin on and around the mastectomy scar of herleft chest (Fig. 1). For Case 2, a physical examination re-vealed a diffuse well-demarcated erythema and edematouscellulitis-like skin on the right side of her chest wall andher back, with a central ulceration on her abdominal wall(Fig. 2) and palpable lymphadenopathy in her bilateral an-terior cervical and supraclavicular chains. Dermoscopicexamination of the two cases revealed a pink-orange back-ground, yellow central areas, linear irregular and poly-morphic vessels, whitish bright lines, whitish structurelessareas, and linear irregular fissure-like depressions. Arecurrence of ductal carcinoma was confirmed with skinbiopsies, and the patients were referred to the oncology

department for further investigations and appropriatemanagement (Figs. 3 and 4).

DiscussionAll types of cancer may metastasize to the skin, with thefrequency of occurrence ranging from 0.2 to 9% amongautopsies carried out on patients with cancer. Skin metasta-ses may occur synchronously or metachronously with thediagnosis of the primary tumor. Occasionally, skin metasta-ses may represent an initial manifestation of an occultinternal carcinoma. Breast and lung cancer are the mostcommon primary types of cancer that metastasize to theskin [4].Patients with breast cancer require differentiation

between skin metastasis and benign dermatologicaldisease. Differences between cutaneous metastases andcellulitis or lymphedema were found most definitivelyon the histologic study of tissue biopsy [5].Advanced metastatic breast cancer is difficult to cure,

and an eventual resistance to cytotoxic treatment isexpected, progression of cutaneous metastases may leadto a fungating mass that would require skin and woundmanagement [5]. Fungating wounds can decrease qualityof life by negatively impacting psychological well-beingand increasing social isolation [6]. This is why the recog-nition of cutaneous metastasis at an early stage is veryimportant for the therapeutic approach, because surgeryof limited lesions may be performed, which is notpossible for advanced stages. For this reason, we thinkthat dermoscopy may be of great help in recognizingthese types of cutaneous metastasis.To date, only a limited number of dermoscopic images

of cutaneous metastatic solid tumors have been published[4]. Cutaneous metastatic breast cancer dermoscopy was

Fig. 1 Case 1: Clinical presentation. Multiple irregularly distributedpink nodules around the indurated mastectomy scar on the leftchest wall

Fig. 2 Case 2: Clinical presentation. Diffusely swollen, erythematous, indurated, and ulcerated skin with a cellulitis-like appearance of the rightchest wall and the back

Kelati and Gallouj Journal of Medical Case Reports (2018) 12:273 Page 2 of 4

Fig. 3 Case 1: Dermoscopy of the skin metastases. Linear, irregular, arborizing and polymorphic vessels at the periphery of purples lesions (bluecircle), structureless yellow areas (red star), bright white lines at the periphery of yellow areas (orange arrow), white structureless areas (violet star),linear skin depressions as fissure-like structures (green arrow)

Fig. 4 Case 2: Dermoscopic image of the skin metastases. Linear, irregular, arborizing and polymorphic vessels (blue circle), structureless yellow oryellow-orange areas (red star), white lines (orange arrow), white structureless areas or around yellow structures (violet star), linear skin depressionsas fissure-like structures (green arrow), and pink structureless areas (blue arrow)

Kelati and Gallouj Journal of Medical Case Reports (2018) 12:273 Page 3 of 4

recently described in two papers of three case reports; thefirst case reported nodular hyperpigmented metastaticbreast cancer, with features of peripheral globules andblue–white veil mimicking a melanoma [7]; recently, intwo other cases, findings of polymorphous vascular struc-tures, whitish depigmentation, umbilicated pits with a ten-dency for forming linear fissure-like structures with small,lateral depressions were reported. These last features werealso noticed in our two cases. As a result, a characterizationof metastatic breast cancer may be performed based onthese patterns; yellow areas were an additional feature inour cases.Polymorphous and atypical vessels are the most fre-

quent vascular structures characterizing malignancy [8];they were also observed in these cases of cutaneousbreast metastasis. However, these structures may be mis-diagnosed as an angiosarcoma or a lymphangiosarcomain Stewart–Treves syndrome after mastectomy where wecan also find white lines as another sign of malignancy[9], the other dermoscopic signs would be of great help,like the yellow-orange color and the fissure-like depres-sions that were described in our two cases.These polymorphic vessels may also have a prognostic

value: the greater the density of the vessels, the more thedisease is invasive, which was observed in our secondcase where the vascularization is abundant and it wasconcordant with an advanced clinical stage; this deservesfurther investigation in prospective studies.

ConclusionsThis is the second dermoscopic description ofnon-pigmented cutaneous metastasis of breast cancer intwo different clinical presentations with similar dermo-scopic features. This may facilitate the monitoring and therecognition of these tumors at an early stage by dermo-scopic examination of the mastectomy scar before the stageof widespread nodules or cellulitis-like erythema.

AcknowledgementsWe are indebted to the two patients who gave their consent for publication.

Availability of data and materialsPlease contact author for data requests.

Authors’ contributionsDrafting the article: KA. Revising it critically for important intellectual content:KA, MF. Both authors read and approved the final manuscript.

Ethics approval and consent to participateThe patients were informed and gave their informed consent.

Consent for publicationWritten informed consent was obtained from the patients for publication ofthese case reports and any accompanying images. Copies of the writtenconsents are available for review by the Editor-in-Chief of this journal.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Received: 28 November 2017 Accepted: 15 August 2018

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9. Zalaudek I, Gomez-Moyano E, Landi C, Lova Navarro M, Fernandez BallesterosMD, De Pace B, et al. Clinical, dermoscopic and histopathological features ofspontaneous scalp or face and radiotherapy-induced angiosarcoma:Dermoscopic patterns of angiosarcoma. Australas J Dermatol. 2013;54(3):201–7.

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https://www.ncbi.nlm.nih.gov/pubmed/?term=prediction+without+pigment+a+decision+algorithm+for+non+pigmented+skin+malignancyhttps://www.ncbi.nlm.nih.gov/pubmed/?term=prediction+without+pigment+a+decision+algorithm+for+non+pigmented+skin+malignancyhttps://www.ncbi.nlm.nih.gov/pubmed/?term=prediction+without+pigment+a+decision+algorithm+for+non+pigmented+skin+malignancy

AbstractBackgroundCase presentationConclusions

BackgroundCase presentationDiscussionConclusionsAcknowledgementsAvailability of data and materialsAuthors’ contributionsEthics approval and consent to participateConsent for publicationCompeting interestsPublisher’s NoteReferences